Adjuvant treatment of postmenopausal women with hormone receptor positive early breast cancer.

Adjuvant treatment of postmenopausal women with early breast cancer (positive or unknown estrogen or progesterone receptor status) who have received 5 years of adjuvant tamoxifen therapy (extended adjuvant therapy).

First-line treatment in postmenopausal women with hormone-dependent advanced breast cancer.

Treatment of advanced breast cancer in women with natural or artificially induced postmenopausal status, who have previously been treated with antiestrogens.

Pre-operative therapy in postmenopausal women with localized hormone receptor positive breast cancer, to allow subsequent breast-conserving surgery in women not originally considered candidates for this type of surgery. Subsequent treatment after surgery should be in accordance with standard of care.

Mechanism of Action: Letrozole is a potent and highly specific nonsteroidal aromatase inhibitor. It inhibits the aromatase enzyme by competitively binding to the heme of the cytochrome P450 subunit of the enzyme, resulting in a reduction of estrogen biosynthesis in all tissues. Letrozole exerts its antitumor effect by depriving estrogen-dependent breast cancer cells of their growth stimulus. In postmenopausal women, estrogens are derived mainly from the action of the aromatase enzyme, which converts adrenal androgens (primarily androstenedione and testosterone) to estrone (E1) and estradiol (E2). The suppression of estrogen biosynthesis in the peripheral tissues and the malignant tissues can be achieved by specifically inhibiting the aromatase enzyme.

In healthy postmenopausal women, single doses of 0.1, 0.5, and 2.5 mg letrozole suppress serum estrone and estradiol by 75-78% and 78% from baseline, respectively. Maximum suppression is achieved in 48-78 hours. In postmenopausal patients with advanced breast cancer, daily doses of 0.1 to 5 mg suppress plasma concentrations of estradiol, estrone, and estrone sulfate by 78-95% from baseline in all treated patients. Letrozole had no effect on plasma androgen concentrations (androstenedione and testosterone) among healthy postmenopausal women after single doses of 0.1, 0.5, and 2.5 mg, indicating that the blockade of estrogen biosynthesis does not lead to accumulation of androgenic precursors. Impairment of adrenal steroidogenesis has not been observed.

Pharmacokinetics: Letrozole is rapidly and completely absorbed from the gastrointestinal tract (absolute bioavailability 99.9%). Food slightly decreases the rate of absorption, but the extent of absorption remains unchanged. The minor effect on the absorption rate is not considered to be of clinical relevance, and therefore letrozole may be taken after, with, or before food. Plasma protein binding of letrozole is approximately 60%, mainly to albumin (55%). The concentration of letrozole in erythrocytes is about 80% of that in plasma. Metabolic clearance to a pharmacologically inactive carbinol metabolite is the major elimination pathway of letrozole but is relatively slow when compared to hepatic blood flow. The cytochrome P450 isoenzymes 3A4 and 2A6 were found to be capable of converting letrozole to this metabolite in vitro, but their individual contributions to letrozole metabolism in vivo have not been established. The apparent terminal elimination half-life in plasma is approximately 2 days.

Adult and elderly patients: The recommended dose of Letrozole is 2.5 mg once daily. In the adjutant and extended adjutant setting, treatment with Letrozole should continue for 5 years or until tumor relapse occurs, whichever comes first. In patients with metastatic disease, treatment with Letrozole should continue until tumor progression is evident. No dose adjustment is required for elderly patients.

Patients with hepatic and/or renal impairment: No dosage adjustment is required for patients with hepatic impairment or renal impairment (creatinine clearance =10 mL/min). However, patients with severe hepatic impairment (Child-Pugh score C) should be kept under close supervision.

Children: Not applicable.

Clinical interaction studies with cimetidine and warfarin indicated that the co-administration of letrozole with these drugs does not result in clinically significant drug reactions, even though cimetidine is a known inhibitor of one of the cytochrome P450 isoenzymes capable of metabolizing letrozole in vitro.

Letrozole is contraindicated in known or suspected hypersensitivity to letrozole, other aromatase inhibitors, or to any of their ingredients. It is contraindicated during pregnancy, lactation, and in premenopausal women. It is also contraindicated in severe hepatic dysfunction.

Common: Hot flushes, increased level of cholesterol (hypercholesterolemia), fatigue, increased sweating, pain in bones and joints (arthralgia), skin rash, headache, dizziness, malaise (generally feeling unwell), gastrointestinal disorders such as nausea, vomiting, indigestion, constipation, diarrhea, increase in or loss of appetite, pain in muscles, thinning or wasting of your bones (osteoporosis) leading to bone fractures in some cases, swelling of arms, hands, feet, ankles (edema), depression, weight increase, hair loss, raised blood pressure (hypertension), abdominal pain, dry skin, vaginal bleeding, palpitations, rapid heart rate, joint stiffness (arthritis), chest pain.

Rare: Nervous disorders such as anxiety, nervousness, irritability, drowsiness, memory problems, somnolence, insomnia, pain or burning sensation in the hands or wrist (carpal tunnel syndrome), impairment of sensation (especially that of touch), eye disorders such as blurred vision, eye irritation, skin disorders such as itching (urticaria), vaginal discharge or dryness, dryness of mucous membranes, weight decrease, urinary tract infection, increased frequency of urination, cough, increased level of enzymes, yellowing of the skin and eyes, high blood levels of bilirubin (a breakdown product of red blood cells).

Oral administration of letrozole in pregnant rats resulted in teratogenicity and maternal toxicity at 0.03 mg/kg. Embryotoxicity and fetotoxicity were seen at doses >0.003 mg/kg, and there was an increase in the incidence of fetal malformation among the treated animals. However, there are no adequate and well-controlled studies of letrozole in pregnant women, and its use in these patients is not recommended. It is not known whether letrozole is excreted in human milk. Because many drugs are excreted in human milk, letrozole should not be administered to a nursing woman.

In breast cancer patients with moderate hepatic dysfunction, no dosage adjustment is necessary, but caution is recommended since letrozole elimination depends mainly on intrinsic metabolic clearance. Renal impairment (calculated creatinine clearance: 20 to 50 ml/min) did not affect steady-state plasma letrozole concentration at a dose of 2.5 mg or 5 mg. Hence, no dose adjustment is necessary for such renal function impairment. It is anticipated that letrozole could be removed from blood by dialysis since it is weakly bound to plasma proteins. The potential risks and benefits to such patients should be considered carefully before prescribing letrozole. In some cases, fatigue and dizziness have been observed with the use of letrozole. Patients should therefore be advised that their physical and/or mental abilities required for operating machinery or driving a car may be impaired.

There is no clinical experience of overdosage. There is no specific antidote to letrozole. Since letrozole is not highly protein-bound, dialysis may be helpful. Emesis may be induced if the patient is alert. In general, supportive care and frequent monitoring of vital signs is appropriate.

Hormonal Chemotherapy

Keep below 30°C temperature, away from light & moisture. Keep out of the reach of children.